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Qualitative research
Original research
Physical and mental health problems of Chinese front-line healthcare workers before, during and after the COVID-19 rescue mission: a qualitative study
  1. Xiangjie Sun1,2,
  2. Zenghui Wang1,
  3. Huan Liu3,
  4. Minmin Ren4,
  5. Danjun Feng1
  1. 1School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
  2. 2Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Jinan, China
  3. 3Department of Hemodialysis, Yijishan Hospital of Wannan Medical College, Wuhu, China
  4. 4Zhongnan Hospital of Wuhan University, Wuhan, China
  1. Correspondence to Professor Danjun Feng; fdj19{at}sdu.edu.cn

Abstract

Objective To explore the physical and mental health problems of front-line healthcare workers fighting COVID-19 across the three phases of the epidemic rescue mission (before, during and after) in China.

Design A qualitative study was adopted using face to face, in-depth semistructured interviews. Phenomenological research methods and Colaizzi’s seven-step analysis method were used in the study.

Setting The setting of the study was the offices of healthcare workers in 12 tertiary hospitals.

Participants Thirty-one front-line healthcare workers from 16 provinces in China, who carried out rescue missions in Hubei Province, were interviewed from October to November 2020.

Results Physical and mental health problems existed before, during and after the COVID-19 rescue mission. Eleven themes emerged during the three phases. Two themes appeared before rescue mission: basic diseases, anxiety before rescue mission. Five themes appeared during rescue mission: basic physical function disorder, physical exhaustion, negative cognition, negative emotions and negative behaviour. Four themes appeared after rescue mission: physical dysfunction, negative emotions, stigmatisation and hypochondriasis.

Conclusion Both physical and mental health problems occurred throughout the three phases. The study results pointed that a comprehensive prevention and control system that addresses both physical and mental health problems of front-line healthcare workers throughout the three phases of epidemic rescue mission (before, during and after), and that involves themselves, their families, hospitals, the government and social organisations is needed.

  • COVID-19
  • mental health
  • qualitative research

Data availability statement

Data are available on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2021-059879

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study explored the physical and mental health problems of front-line healthcare workers (HCWs) who carry out epidemic rescue mission, through a unified perspective of mental and physical health and through a qualitative study.

    • The sample size of this qualitative study was comparatively large, and the study sample was diverse.

    • Due to the uniqueness of the sample, the results of the study should be generalised with caution to HCWs fighting against other infectious disease outbreaks, especially those in other countries.

    Introduction

    In the past 30 years, there have been more than 40 new types of major epidemic around the world, including severe acute respiratory syndrome, Middle East respiratory syndrome, pandemic influenza 2009 and so on.1 2 According to WHO data, major epidemics were once the second highest cause of death.3 For example, COVID-19 outbreak has been associated with significant morbidity and medical complications around the world; by 8 December 2021, 267 244 380 people had been infected with COVID-19 and there had been 5 280 678 deaths globally as of 8 December 2021.4 Major epidemics are characterised by high infectivity, pathogenicity and mortality,5 which not only directly threaten the survival and development of human beings but also have considerable impact on the world economy.

    Front-line healthcare workers (HCWs) are an important resource in every country. They play a vital role in controlling the spread of an epidemic, reducing casualties and ensuring economic development and social stability.6 In early 2020, the Chinese National Health Commission sent HCWs from other provinces to support COVID-19 outbreak areas, and most had no prior experience carrying out epidemic rescue mission. These HCWs suffered various health problems due to epidemic rescue mission-related stressors, which, as previous studies found, included high intensity of work, high risk of viral infection and ethical issues.7 Moreover, HCWs also experienced environment-related stressors such as harsh working environments, long periods of wearing personal protective equipment (PPE), cultural differences and lack of protective supplies.8 9 These stressors made HCWs easily susceptible to both physical and mental health problems (such as viral infection, depression and anxiety) during the rescue mission.10 HCWs with health problems not only reduce the quality of the provision of continued patient care, but also hinder a flexible response to the control of an epidemic.11

    Extant studies have found that HCWS are prone to suffer viral infections and mental health problems.10–12 However, these studies mainly focused on the mental health problems of HCWS in two phases (during and after the rescue mission) through quantitative studies with scales.3 13 Only one study found that HCWs also experienced mental health problems (tension, hopelessness and fear) before arriving at the epidemic rescue mission scene.14 What’s more, according to the stress response theory, individuals exhibit dual physical and mental responses when facing various stressors. This means that when HCWs carry out epidemic rescue mission, which is an experience that induces considerable stress, they may have physical and mental health problems. Finally, the current studies also neglect the physical health problems among HCWs in three stages of epidemic rescue mission. If the physical and mental health of HCWs is ignored, the health of HCWs cannot be effectively protected. This will ultimately seriously reduce the ability to manage major epidemics in the future. Thus, it is necessary to focus on the physical and mental health of HCWs and explore their physical and mental health problems in different phases of epidemic medical rescue mission (before, during and after).

    This study adopted a qualitative research design to explore both physical and mental health problems in the three phases of epidemic rescue mission (before, during and after) of HCWs fighting COVID-19 in Hubei Province, China. It serves as a reference for preventing or solving these health problems and ultimately contributing to better protection of the health of HCWs fighting COVID-19 and other major epidemics in the future.

    The study

    Aim

    This study aimed to explore physical and mental health problems of HCWs in different phases of COVID-19 epidemic rescue mission (before, during and after).

    Design

    Qualitative research is typically used to acquire an in-depth understanding of individuals’ experiences under specific circumstances.15 Phenomenological study is a qualitative research method that analyses the inner and outer components of a particular phenomenon, extracts the important elements of the phenomenon, and explores the relationships among the elements in the surrounding context. Phenomenological study requires the researcher to bracketing prior concepts and preconceptions, and to focus on life experiences, and returning to the phenomenon itself, thus contributing to the understanding of people, behaviours and the meaning behind the phenomenon.16 COVID-19 is a new infectious disease. The epidemic rescue mission that HCWs are involved in is a new experience and completely different from their daily work. Therefore, it is appropriate to explore the health problems of HCWs during COVID-19 epidemic rescue mission using a phenomenological approach to aid the deeper understanding of the various important elements and their relationships behind the phenomena. This study followed the guidelines for Consolidated Criteria for Reporting Qualitative Studies (checklist, see online supplemental table S1).

    Participants

    Purposive sampling was used to enrol HCWs who participated in the epidemic rescue missions in Hubei Province, China, during the COVID-19 outbreak in 2020.

    The inclusion criteria for the participants were that they had to have travelled to Hubei Province to fight COVID-19 for at least 1 month. Participants were excluded if they were auxiliary or logistic HCWs.

    Data collection

    The study was conducted in October and November 2020, 6 months after the completion of the rescue mission in Hubei. First, the HCWs’ group manager forwarded participant recruitment information to WeChat workgroups. This included the study’s aim and methods (interviews), inclusion criteria, information on the voluntary nature of the study and the ability to withdrawal at any given time even after agreeing to participate in the interview, and researcher contact information (ie, mobile phone number) to confirm participation. The interview required participants to respond to four open-ended questions related to their experiences during their epidemic rescue mission. If they had any negative emotions, unreasonable thoughts or other unpleasant experiences, some psychological services could be provided (eg, professional psychological assessment and counselling, stress management and emotional regulation training). Second, HCWs who were interested and agreed to participate in the study contacted the researcher by mobile phone. The interview was scheduled in a quiet, relaxed and private room for face-to-face interviews without any disturbances.

    HCWs with varied demographic backgrounds were selected to ensure sample representativeness. Data collection occurred concurrently with the data analysis, which may have facilitated the identification of thematic saturation. The sample size was not certain until theoretical saturation was achieved, when no new information was identified in the analysis.17

    Face-to-face and semistructured interviews were conducted by five experienced researchers, including one professor, three postgraduate students and one clinical nurse who had been trained in qualitative interviewing methods and ethics. An interview guide based on an extensive literature survey of HCWs’ health problems was developed for the interviews. Then, two HCWs who battled COVID-19 in Hubei were preinterviewed to familiarise the interviewing researchers with the study’s progress and to modify the interview guide (for the final interview guide, see box 1).

    Box 1

    Semistructured interview guide

    Questions

    1. What worries did you have when you were informed that you were going to work in hospitals in Hubei Province?

    2. Did you feel uncomfortable physically or mentally when you arrived in Hubei Province?

    3. Did you feel uncomfortable physically or mentally when you worked in the isolation ward?

    4. How has your physical and mental health changed after the rescue work compared with before the rescue work?

    Before the interview, the participants decided on a quiet interview space (such as, meeting room) by mobile phone. At the beginning of each interview, they were asked to provide their demographic information via a questionnaire. Then, with the participants’ permission, all interviews were audiorecorded using a small recording device. The interviews lasted between 20 and 60 min. An interview guide was followed, and the discussions on the topics were open and flexible.18 The researchers encouraged the interviewees to be expressive. During the interview, interviewers wrote down their observations about the participants’ body language and their own reflections so that the participants’ perspectives would be correctly understood and described. In addition, appropriate pauses or changes in a topic were applied whenever the participants seemed to feel uncomfortable during the interviews. Subsequent telephone interviews were conducted if there was any doubt about the content of the interview. The HCWs were compensated RMB100 for taking part in the interview.

    Data analysis

    Data collection and analysis occurred simultaneously and were managed using Nvivo V.11.0 software (QSR International, Doncaster, Australia). Within 24 hours from the end of the interview, the recording was transcribed word-for-word. Haase’s19 adaption of Colaizzi’s20 method was used to analyse the transcripts. First, the researchers read every transcript several times to gain a thorough understanding of the meanings conveyed. Second, significant statements and phrases were identified from each transcript. Third, the researchers described and analysed the aspects of the data that were not obvious, explicit statements in each transcript. The researchers then integrated all of the results into an exhaustive narrative description, and they also created and validated formulated meanings through research team discussions to reach consensus. Fourth, these formulated meanings were sorted into clusters of themes and categories. Fifth, the researchers identified the fundamental structure of the experience and developed a full and clear description of each of the six themes. Finally, to validate the study, the researchers asked the participants if the findings captured the essence of their experiences. To enhance confirmability, three researchers independently analysed the transcripts. Thereafter, findings from the researchers were compared and discussed at team meetings until consensus was achieved.

    All participants provided verbal consent at the beginning of the individual interview. Anonymity and confidentiality were maintained by replacing names with numbers (eg, I1) and by removing identifying information from the transcripts. All transcripts were saved on a password-protected computer. In addition, we followed the standards for reporting qualitative research guidelines.

    Rigor

    Linclon et al21 four criteria for evaluating trustworthiness (credibility, transferability, dependability and confirmability) were used to enhance the rigour of the study. The research team consisted five experienced researchers, including one professor, three postgraduate students and one clinical nurse. The interviews were performed by three experienced researchers who had been trained in qualitative interviewing methods and had prior experience performing qualitative research. The data were analysed by each researcher independently, to ensure reliability and validity. The findings from each researcher were compared. Differences in findings were resolved through discussion and consensus. Thick description and verbatim quotes were used to ensure the transferability of the findings. The researchers included experts from HCWs’ statements to verify the concordance of findings with raw data. This method was used to enhance the confirmability of the data and to illustrate that data were not based on preconceived notions. All decisions regarding data collection and analysis were recorded and an audit trail was maintained to establish the dependability and confirmability of the study.

    Patient and public involvement

    As this study focused on the health problems of HCWs fighting COVID-19, the patients and the public were not involved.

    Results

    The participants in this study were 15 women and 16 men, aged between 24 and 50 years. Eighteen were nurses and 13 were doctors. The characteristics of the participants are summarised in table 1. Eleven main themes were identified from the HCWs’ dataset (figure 1).

    View this table:
    Table 1

    Sociodemographic data of interviewers

    Figure 1
    Figure 1

    Preliminary codes, initial thematic framework and final themes.

    Before the epidemic rescue mission

    Physical health problems before rescue mission

    Some participants had underlying diseases (systemic lupus erythematosus, asthma and allergic constitutions) when they received their epidemic rescue mission notice. Undoubtedly, they were at high risk of being infected or even dying during the rescue mission. ‘I had an allergic constitution. I didn’t mention that. The leaders didn’t know. At first, I really wanted to join in the rescue work. I was afraid that others would prevent me from participating in this work because of this disease.’ (I16)

    Mental health problems before rescue mission

    The most common mental health problem the participants experienced before rescue mission was anxiety, especially for those who had never participated in such an operation before. They cited two main reasons for their anxiety. The first reason was that they feared of being infected by COVID-19. ‘I was really worried when I first went there on February 7. At that time, it was said that the number of cases there were increasing every day. It was the first time that I had been involved in the epidemic rescue mission, and I was very worried.’ (I4) The second reason was that they were very anxious because they were unable to handle family affairs or protect the health and safety of their family members. ‘My old parents and my father-in-law were still in the hospital, and I have two children. I was worried that if something happened suddenly, there would be nobody helping my family.’ (I23)

    During the epidemic rescue mission

    Basic physiological function disorder during rescue mission

    Some participants said they suffered arrhythmias, chest tightness, breathing difficulties and even fainting because of such factors as high-intensity work, circadian clock disorders, and hypoxia resulting from wearing PPE. ‘Most of the time, I did not have arrhythmias. But when I was lying in bed, I had premature heartbeats and arrhythmia. Anyway, I felt uncomfortable at that time.’ (I14)

    Because of the airtightness of the PPE and the irritation from disinfectants, participants experienced symptoms of hypoxia and carbon dioxide retention, which eventually led to a decline in lung function. ‘When our medical team was relaxing in the hotel at night, I frequently heard my colleagues coughing. It was a common problem for everyone because wearing an N95 mask affected one’s own lung function. It was also stated in the literature that wearing an N95 mask in such an enclosed environment for a long time affects people’s lung function.’ (I5)

    The participants suffered from gastrointestinal problems, including nausea, vomiting, diarrhoea, and stomachache because of poor diet, physical hypoxia, and mental stress. ‘Not long after I entered the ward, I suddenly felt uncomfortable. I immediately vomited in the protective suit and the N95 mask I was wearing.’ (I26)

    Some participants had endocrine symptoms such as hypoglycaemia and menstrual disorder. Participants often went to work without having breakfast in order to avoid vomiting and wasting equipment, which placed them at high risk for hypoglycaemia. For female participants, the high intensity of rescue mission -had led to menstrual disorder. ‘During the rescue period, the menstrual period moved forward by half a month, that is, 3 times in 2 months.’ (I14) ‘You had to eat at the end of the day, which means that you had to spend about 7 or 8 hours in the ward before you ate. So, there were many people who had hypoglycemia at that time.’ (I28)

    Physical exhaustion during rescue mission

    During rescue mission, the participants’ physical capabilities deteriorated significantly as a result of wearing PPE, frequent shifts, insufficient personal rest time and high-intensity work. ‘In the early days, because there was not enough protective equipment, we had to wear diapers and left after being in the ward for more than 10 hours. This working model was adopted so as not to waste any equipment. So, we did not leave the ward until we could not hold on. Our physical exhaustion was the most serious in the early stages of the rescue.’ (I7)

    The participants reported that they had symptoms of device-related skin injuries, dermatitis, rashes, nasal mucosal injuries and oral ulcers because of the prolonged use of sealed PPEs, frequent use of harsh disinfectants, and a rather simple, non-nutritious diet. ‘One person in our rescue team who worked for 2 days straight after coming to the ward had rashes on his scalp. At that time, he couldn’t go to work because he was afraid of being infected because of those rashes.’ (I21) ‘In the early stages of the rescue, there were no vegetables available.’ (I7)

    The participants were at high risk of being infected with COVID-19 because of their close contact with patients and the strain of the work. ‘What affected me the most was that six people in the original department of the hospital where we worked as rescuers had already been infected.’ (I15) Likewise, there was also a risk of death. Some participants had cardiac arrest and died suddenly because of long-term fatigue. ‘There was a nurse who fainted due to hypokalemia, and then she had a heart attack.’ (I9)

    Negative cognition during rescue mission

    The participants had a strong sense of being protected when they first arrived at the ward to work. However, in the later stages, when they had become familiar with the protection procedures, their sense of self-protection diminished as they realised they were at an increased risk of infection. ‘One month later, the team members, including myself, had a weak sense that we could prevent infection because we had worked for a month without infection.’ (I21)

    The participants suspected that they were infected, without clear medical evidence. This phenomenon is referred to as hypochondriasis. ‘I was very nervous after I had been coughing for 2 or 3 hours. I was very sensitive because the symptoms of COVID-19 include asymptomatic dry cough.’ (I15)

    The participants sometimes thought that they were unable to save the patient’s life, which lowered their sense of efficacy. ‘Treatment was a worrying thing because there was no standard treatment strategy for COVID-19. The treatment guide was updated seven times a month. I did not know how to treat the disease effectively.’ (I12)

    Negative emotions during rescue mission

    The main emotional problem that the participants dealt with during rescue mission was the fear of being infected by the virus. This fear stemmed from the suspicions of those around them that they were experiencing symptoms of infection and because of the ineffectiveness of the PPE. ‘In fact, I was mainly worried about infectious diseases, including being infected myself, and the risk of transmitting the virus to others.’ (I4)

    When participants entered the ward, the challenging tasks their work entailed made them anxious. ‘At that time, the need to minimize the mortality rate was urgent. Therefore, we were under enormous pressure to treat critically ill patients who were often at a higher risk of death.’ (I6). Personal inner conflict was also a cause of anxiety. ‘I had a conflict because I needed an assistant, a nurse, a doctor … and at least five people around me when performing the intubation surgery. The virus formed aerosols that could infect anyone. At that time, I wondered whether it was worth saving a patient with low hopes of survival when it put so many medical staff in danger.’ (I7)

    The participants were prone to feelings of helplessness because of their inability to socialise, the shortage of protective and medical equipment, the ineffectiveness of the treatment of patients, and their inability to handle family matters. ‘The next day after I arrived in the ward, I didn’t get any supplies except the bare minimum. I did not think we could protect ourselves without any protective supplies. It was a really desperate situation.’ (I7)

    The participants were required to isolate themselves, which resulted in their being away from family and colleagues, and experiencing a sense of loneliness. ‘We were working in the separate rescue ward alone. Thus, at that time, we had no contact with anyone else for 2 months and we were isolated.’ (I15)

    Negative behaviour during rescue mission

    Due to the high intensity, long durations and high risk of the work performed during rescue mission, some participants exhibited negative behaviour problems, such as overeating, compulsive behaviour and avoidance behaviour.

    Some participants relaxed by overeating. ‘I tended to relax by eating lots of food. Finally, I had gained 10 kg after the rescue mission.’ Many HCWs also suffered from insomnia because of the high stress. (I3) ‘To be honest, I hardly slept for a week.’ (I24)

    The participants engaged in compulsive behaviours, including excessive hand-washing and other excessive protective behaviours because they worried about being infected by COVID-19. ‘The phenomenon of overly protective behavior also existed because of inner tension. In fact, we pressed hard [on the nose clips of our masks] out of fear of infection, which resulted in breaking the skin.’ (I8)

    The participants exhibited social avoidance, work avoidance and avoidance of epidemic-related information. ‘I did not want to call my family members. I’m sure that I deliberately avoided talking about the rescue work with my family.’ (I15)

    After the epidemic rescue mission

    Physical disfunction after rescue mission

    Some participants overate to relieve stress, causing them to gain weight. However, most people suffered a loss of appetite, causing rapid weight loss. ‘Everyone said that they were thinner as they weighed around 6–7 kg less than before.’ (I14)

    Because of the high intensity of work, some participants exhibited cardiocerebrovascular symptoms, including myocardial ischaemia, angina pectoris, palpitation, chest tightness, lacunar cerebral infarction and elevated blood pressure. ‘After we came back, we had a physical examination and there was lacunar infarction in our team members. But they had no lacunar infarction before.’ (I9)

    The participants reported respiratory symptoms, including throat discomfort, pulmonary nodules, ground glass changes in the lungs, and respiratory infection. ‘I was diagnosed with a lung problem after physical examination.’ (I7)

    Some participants experienced endocrine symptoms, including elevated blood sugar levels, and some female rescuers also had symptoms of menstrual disorders. ‘The physical examination showed that my blood sugar was a little higher than before. There were also many women who found that their menstrual periods had changed.’ (I7)

    Low back or cervical pain was also a symptom reported by some participants. ‘I had to bend over to administer medication, which led to cervical spine pain and back pain. I didn’t feel the pain before, but now it’s very painful.’ (I29)

    Many participants found that their immunity had declined and they had more frequent colds and rhinitis. ‘I often had colds; they were more frequent than before.’ (I21)

    Negative emotions after rescue mission

    The participants had to avoid contact with others during quarantine, which caused many to experience loneliness. ‘I thought isolation made me more uncomfortable than working. I could not go out and see anyone during quarantine.’ (I16) They also found themselves tending to hide their own physical and mental health problems. ‘Chinese people are relatively unwilling to talk about their psychological conditions. I thought it was a normal phenomenon. There were many psychological problems among our team members but it was difficult for them to take the initiative to speak out.’ (I6)

    The participants experienced nightmares, increased alertness, and avoidance behaviour as the main symptoms of post-traumatic stress disorder (PTSD). ‘During our isolation and recuperation, I had a nightmare every day.’ (I12) ‘When I returned to work, I saw the patients in the ward. I felt so nervous because I was afraid that the patients needed oxygen. And then I immediately prepared oxygen for them.’ (I29) ‘Sometimes I am reluctant to remember the rescue experience.’ (I8)

    When the rescuers heard the news of the accidental deaths of their colleagues, they would be fearful and worried that they too might die suddenly. ‘After her [the colleague] death, we were really under a lot of pressure. It was possible that I might die suddenly. I didn’t dare to go to sleep because I was afraid that I would die suddenly in my sleep.’ (I1)

    Some participants experienced depression after returning home. ‘There was a mental health examination provided by the hospital, for which many had abnormal results. One of them had suicidal tendencies.’ (I1)

    Stigmatisation after rescue mission

    Many participants faced stigmatisation. During the quarantine period, hotel staff treated them differently for fear they might spread the virus. After returning home, the participants’ neighbours also worried about catching the virus from them and avoided contact with them. ‘My mother told me that the people near our house didn’t want to allow me come home because I had been to Wuhan.’ (I29)

    Hypochondriasis after rescue mission

    Even after the epidemic rescue mission was over, some participants continued to have symptoms of hypochondria. They believed that they were either infected or mentally ill. ‘I had a sore throat in the quarantine hotel and I thought I was sick. But my blood revealed no problems in the nucleic acid test at that time.’ (I5) The problem of insomnia also persisted after the participants finished the rescue work. ‘I think the biggest problem is insomnia. When I was in quarantine and even when I went back to work, I had symptoms of insomnia.’ (I13)

    Discussion

    The novelty of this study lies in its use of first-hand interviews to deeply explore of the physical and mental health problems of HCWs fighting COVID-19. The results revealed that HCWs had quite serious physical and mental health problems before, during and after their participation in epidemic rescue mission. This study compensates for the shortcomings of previous studies on the health problems of these HCWs, which, to some extent, have ignored the health problems that existed before the rescue mission. There is an urgent need for measures that protect the health of these HCWs throughout the three phases of epidemic rescue mission is urgent.

    This study observed a worrying phenomenon of participants hiding their underlying diseases before the rescue work. This behaviour may be associated with strongly held beliefs regarding professionalism in the healing of infected people.22 Because an extended period of stressful rescue work may cause diseases of various organs,23 the underlying diseases of rescuers undoubtedly increase their risk of sudden death during and after rescue mission.24 Therefore, hospital administrators should conduct physical and mental health examinations of these HCWs in order to identify high-risk individuals.

    During rescue mission, the participants reported experiencing respiratory, cardiocerebrovascular, gastrointestinal and endocrinal problems. These symptoms were related to the high physical and mental stress and prolonged wearing of PPE. Unlike most previous studies that focused on fatigue but overlooked the causes of the fatigue among these HCWs,25 this study found that the burden on the respiratory, cardiocerebrovascular, gastrointestinal and endocrine systems may be the reason for the fatigue experienced. Therefore, the hospital administrators should regularly monitor the health status of HCWs who carry out epidemic rescue missions and provide prompt treatment of problems. In addition, this study revealed that the physiological function disorder experienced during rescue mission continued for a long period of time after the mission had ended. This finding was in line with those of prior studies. For example, a cohort study showed that Chinese front-line nurses continued to show somatic symptoms after returning from the rescue missions.26 Therefore, hospital administrators should persistently follow-up on the health status of HCWs even after the completion of the rescue work.

    The participants reported experiencing emotional problems as well as physical problems throughout the rescue mission. Among the negative emotions experienced, anxiety was the most prevalent before and during the rescue work. Similarly, Zakeri et al27 found that 18.8% and 34.7% of Iranian nurses had severe anxiety before and during the epidemic, respectively. The results of the interviews suggested that the main stressors causing anxiety among HCWs before the rescue mission were due to fear of infection and of infecting family members. Therefore, it is important for hospital administrators to reduce HCWs’ anxiety by eliminating these stressors. We found that helplessness was another common emotion experienced during rescue mission, and this finding was in line with those of a previous qualitative study.28 The previous study found that the high sense of helplessness was primarily caused by the ineffectiveness of the treatment given to patients. Our results showed that the inability to socialise or manage housework, and the shortage of medical equipment were other factors that increased the sense of helplessness. Helplessness not only contributed to more mental problems, but also increased job burn-out and turnover intention.29 Thus, it is valuable for hospital administrators to reduce helplessness through psychological interventions. In addition, during and after rescue mission, loneliness was another emotional problem experienced. This finding concurred with that of a previous study in which Italian HCWs reported that living in an isolated environment to avoid cross-infection increased their loneliness during the pandemic.30 Therefore, the problem of loneliness needed to be addressed by increasing HCWs’ online social activities.

    Another concern was the negative behaviour of participants during the rescue mission. Eating problems were very troublesome. The participants with overeating behaviour were more likely to vomit during work. Those who abstained from food or consumed less to avoid vomiting were prone to develop symptoms of hypoglycaemia. Therefore, hospital administrators should pay more attention to the eating habits of HCWs. In addition, we also found a new phenomenon of social avoidance. The participants avoided communicating with their family members although they had sufficient opportunities to make contact during rescue mission. A probable explanation for this finding was that due to the influence of Chinese family-oriented culture, participants chose not to communicate with their family members to avoid exposing their poor physical and mental status, and thereby relieve family members’ concerns about their health status.31 Social avoidance could have led to a lack of social support, which made these HCWs more susceptible to epidemic-related stress and more physical diseases.32 Thus, it is important for hospital administrators to intervene by urging HCWs to develop a plan to regularly communicate with their family members.

    This study also found negative cognition in participants, which was consistent with the findings of Simonetti et al.33 Simonetti et al found that 50.65% of Italian nurses had low self-efficacy during the pandemic. Another previous study showed that front-line nurses’ low efficacy reduced their use of a positive coping strategy and increased the incidence of PTSD.34 Therefore, it is necessary for hospital administrators to resolve this issue. Moreover, this study witnessed a new phenomenon, where HCWs’ sense of self-protection gradually reduced as the rescue process progressed, which made them more susceptible to infection. Therefore, hospital administrators should constantly remind HCWs to strengthen their self-protection awareness and behaviour.

    Some participants reported experiencing stigmatisation when they returned home, because the individuals around them were afraid of being infected. These findings concurred with those of a previous study.35 Jain et al36 found that the HCWs generally perceived more stigmatisation from the public and internalised this discrimination. This resulted in them regarding themselves as infection sources which reduced their ability to interpersonally interact with others. Therefore, hospital administrators should provide these HCWs with cognitive interventions that eliminate these unreasonable cognitive biases. Moreover, some participants showed hypochondriasis after the rescue mission. For example, when the participants coughed, they suspected that they were infected. Thus, the hospital administrators should conduct preventive physical and mental health examinations on HCWs to differentiate between actual and perceived diseases. HCWs who are diagnosed with an illness should be promptly treated. Those with hypochondriasis should be provided with mental health education and stress management training to help promote their mental health recovery.

    A similar phenomenon was also found for the phase after the rescue mission. Some emergency health workers hid their physical and mental discomfort out of shame, which may be related to face culture in China.37 This behaviour is not only a high-risk factor for the development of more serious physical and mental illness but also an obstacle to resuming a daily routine after the rescue mission.38 Therefore, colleagues and family members should be sensitive to the HCWs’ abnormal physical and mental reactions through observation and communication.39 Furthermore, hospital managers should establish early screening programmes to monitor the early signs of physical and mental health problems among these HCWs.40

    Implications for future practice

    This study had two major implications for future practice. First, because HCWs face many stressors during epidemic rescue mission, the protection of their health must not be the sole responsibility of HCWs themselves.41 They should be provided with both material and moral support, both of which can decrease the risk of their suffering health problems and improve the efficiency of patient care.42 Thus, hospital administrations should cooperate with others to establish a comprehensive prevention and support system.40 Second, epidemic rescue mission has long-term impacts on the health of HCWs, as this study confirmed. Therefore, it is necessary for hospital managers to establish long-term health profiles of HCWs to track and solve their health problems after epidemic rescue mission.

    Limitations

    A limitation of this study was that all participants were interviewed nearly 6 months after their epidemic rescue mission, which might have caused recall bias. However, because this was the first time that most HCWs had ever experienced working during major epidemic, their recollection of the experience was relatively clear, as was confirmed during the interviews. Further studies should collect information about HCWs health problems during each phase of the epidemic rescue mission (before, during and after) to reduce recall bias. Furthermore, the participants in this study were HCWs involved in the epidemic rescue mission of COVID-19 rescue mission in Wuhan, China, and therefore, the results of this study are not generalisable to HCWs fighting against other infectious disease outbreaks especially those in other countries. Finally, as a qualitative study, this study could not estimate the frequency and severity of these health problems reported, and thus, future quantitative studies are needed to make up for this deficiency.

    Conclusion

    HCWs fighting COVID-19 experience physical and mental health problems before, during and after epidemic rescue mission. To protect their health, a comprehensive prevention and control system is needed that covers both physical and mental health problems and involves the HCWs themselves, their families, hospitals, the government and social organisations in each phase of the rescue missions.

    Data availability statement

    Data are available on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study was approved by the Ethics Committee of the School of Nursing and Rehabilitation of Shandong University (No. 2020-R-39).

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    Supplementary materials

    • Supplementary Data

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    Footnotes

    • Contributors DF conceived of the study, participated in its design and coordination, and helped to draft the manuscript, who is responsible for the overall content as a guarantor; XS participated in the data analysis and interpretation of the data and drafted the manuscript; ZW helped to draft the manuscript; HL participated in the data collection; MR helped to draft the manuscript.

    • Funding This research was supported by the National Social Science Fund of China (Grant number: 20VYJ025).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.